Terms of Service 1 — CG Pilates

Name

First Name

Last Name

Telephone number

Emergency Contact Name & Number

Heart disease, high blood pressure or any other cardio vascular problem

Have you ever suffered from heart disease, high blood pressure or any other cardio vascular problem

Is there a history of heart disease in your family under the age of 50

Have you ever had chest pains?

Do you ever feel faint of have spells of dizziness?

Have you had a medical condition, which you think may interfere with your participation in any exercise programme?

Have you had a medical condition, which you think may interfere with your participation in any exercise programme? If yes please give details in the notes section at the bottom of the form.

Are you taking medication at the moment? If yes please give details

Select Are you recovering from a recent illness or operation

Are you recovering from a recent illness or operation

Do you have any injuries, which you think may limit your ability to exercise?Select

Do you have any injuries, which you think may limit your ability to exercise?

Are you pregnant or have you had a baby in the last 6 months?

Are you a newcomer to exercise and aged over 35 (male) or 45 (female)?

Do you smoke

Do you smoke?

Additional information

If you have answered yes to any of the above questions, please give further information in the text box below. You may also need to get clearance from your doctor before starting any exercise programme.

How long have you exercised?

Exercise History How long have you exercised? (please state in months & years)

What exercise have you been doing recently?

What exercise have you been doing recently? Please also confirm intensity from hard, medium to light.

How often have you exercised?

How many hours per day do you spend sitting? Please state: 0-2 / 2-5 / 5-8 / 8+

Please add any additional information here:

Agreement of Health Screen

I acknowledge that I have not withheld any relevant information relating to my present health status. I understand it is my responsibility to inform my Instructor of any future changes in health that may occur or of any problems I experience while exercising. Whilst safe and effective exercise may produce many health benefits, it is important to realise there is also the low possibility of exercising causing come difficulties. It is recommended that to avoid any risk, you start to exercise at a low level and gradually build up your fitness. Initially you may experience some local muscular soreness and slight fatigue, but as the programme continues, they should disappear. I understand that there may be a small risk in starting an exercise programme and I undertake to inform my instructor if I experience any problems while exercising.

Yes I agree

No I do not agree

Signature

Date of completion

Health Screening Form